Review committee for otolaryngology case log coding. Gracilis flaps for breast reconstruction plastic surgery key. Reconstruction for congenital deformities is covered under the topic of urogenital reconstruction, while penile and vaginal reconstructions are covered separately in this journal. Muscle conserving free gracilis transfer minigracilis free flap ncbi. Double free muscle transfer using the gracilis muscles is a potentially effective method of restoring upper extremity function. Muscleonly gracilis flaps had a significantly reduced healing time compared to musculocutaneous gracilis flaps 48 days vs 85 days, p 0. Modified technique of gracilis flap harvest condyle between the sartorius and semitendinosus muscles.
Any information contained in this pdf file is automatically generated from digital. Each flap was inset under adequate resting tension such that functional thumb opposition would occur with gracilis contraction. The transverse upper gracilis free flap is a welldescribed option for breast reconstruction. The gracilis muscle is located in the inner aspect of the thigh. A small portion of this muscle with its blood supply artery and vein and nerve can be transplanted in the face to replace the facial muscles that allow you to smile. We have repaired a rectoneovaginal fistula through a transvaginal approach and using gracilis flap interposition figure 9a,b,c.
A standardized surgical technique was used for harvesting and inset of gracilis flaps. A prospective comparison of outcomes, patient satisfaction and aesthetic results. It should help clarify some questions that you may have. In reconstructive techniques, the use of the composite gracilis skin flap may be complicated by a total or partial necrosis of the cutaneous paddle. Superficial skin markstitch placed on skin over vessels. In the past, patients were instructed to cease dilation to allow the neovaginal canal to close, thus treating the fistula but leading to loss of the neovaginal canal. In 1990, obrien was the first to report the use of the gracilis free flap for singlestage facial reanimation. Both flaps were covered with a split thickness skin graft and in each case there was careful preservation of the gracilis epimysium in order to minimise possible tethering.
Treating brachial plexus injuries is a major challenge, especially lesions that are presented late, with more than 12 months of evolution. The gracilis muscle has a consistent and reliable blood supply and has been well described 1,2. Lokaler weichteilschaden an beiden oberschenkeln medialseitig. The linear incision in the medial thigh is made at the inferior border of the adductor longus to expose the gracilis. The belly of the muscle can be rotated and inserted as a flap between the rectum and adjacent organs during the repair of fistulas, or used as filler for the repair of nonhealing perineal wounds, with the option of harvesting an island of skin from the medial aspect of the thigh as a myocutaneous flap. Technique of harvesting the gracilis for free functioning muscle transplantation article pdf available in techniques in hand and upper extremity surgery 104. Gracilis muscle interposition in conjunction with primary rectal repair but without urethral reconstruction is one of the reconstructive surgery options for moderate 2cm to 3cm rectourethral fistulas. Pdf surgical outcomes of vram versus gracilis flaps for. Its major advantage is its ability to be reinnervated through the. The gracilis myocutaneous flap is favoured by many reconstructive surgeons due. The transverse upper gracilis tug flap uses tissue from the inner upper thigh near the natural groin crease, as well as the gracilis muscle, to create breast tissue.
A flap reconstruction may suit women who have large breasts, women who dont have enough skin to cover an implant, or women who have had radiation therapy. Peterson md, facs professor of surgery duke university durham, nc. As an additional feature, im proud to announce that this supplement will be made available free online. Medial sural artery perforator flap in lower extremity reconstruction the alt flap, a workhorse also as a pedicled flap 1 free ipsilateral extended anterolateral thigh flap alt flap with vein grafts for soft tissue. The fleurdelis upper gracilis flap versus deep inferior epigastric perforator diep flap for bilateral breast reconstruction in thin patients. Free flap surgery preoperative management long ot painful key rx is to minimise warm ischaemic time operations. We retrospectively analyzed patients who underwent one of the possibilities for attempting to restore the function of upper limbs affected under such conditions. As a pedicled flap, gracilis muscle can be used in perineal and vaginal reconstruction, after oncological surgery. This pdf is available for free download from a site hosted by medknow publications.
The gracilis free flap is a viable option for large extremit. Skin graft a skin graft is a procedure performed where healthy skin is removed from one area of the. Flap inset is performed either in lithotomy or jackknife prone, dependent on colorectal surgeon preference for resection and patient body habitus. The gracilis flap is an exciting alternative to abdominal, back, or buttock tissue flaps for reconstruction of a naturallooking and soft, shapely breast. Moore, do from atlanta urogynecology associates, atlanta georgia all authors. The profunda artery perforator pap flap is a useful alternative that has addressed some of the morbidity associated with the tug. Traumatic brachial plexus root avulsions are devastating injuries, and are complex and challenging to reconstruct. According to the place where this insertion is made, the site figure 1 removal of flap from gracilis. However, the pap flap may result in distortion of the gluteal crease and lead to sensory changes in this region. The gracilis free flap is the ideal modality of emotive and spontaneous facial reanimation in patients with a viable contralateral facial nerve. Functional free muscle flap facial paralysis surgery. It is based on branches to the gracilis from the medial femoral circumflex system. One major criticism of the gracilis flap is the questionable viability of the cutaneous paddle when used as a myocutaneous flap due to inconsistent perforator supply.
Feasibility of gracilis muscle flap interposition for management of. Click add files and select the files you want to include in your pdf. The gracilis muscle free flap is generally performed as a 2stage procedure. Review committee for otolaryngology case log coding recommendations. Cleveland clinic florida colorectal chairman steven wexner, md, examines the evidence in our viewpoints series. Gracilis myocutaneous free flap american head and neck society. In this article, the anatomy of the gracilis muscle, alternative neural sources including the masseteric nerve, and. Technique of harvesting the gracilis for free functioning muscle. Tissue from the inner thigh has a significant amount fat of that can be sculpted to form a breast. The gracilis flap is a good choice for perineal wounds should you be opting for a gracilis flap. The gracilis myocutaneous flap is favoured by many reconstructive.
Muscle conserving free gracilis transfer minigracilis. Laparoscopic davydov correction of a failed gracilis flap neovagina in a patient with mayerrokitanskykusterhauser syndrome with a pelvic kidney christopher r. Video presentation 08 rectovaginal fistula repair using a. The gracilis muscle helps bring the leg toward the body, and its function will be lost after this type of surgery. Horton introduction the inner thigh skin and fat based on the transverse upper gracilis tug musculocutaneous flap blood supply provides an autologous donor area with several qualities complementary to microvascular breast reconstruction. The shape of a breast can be built using muscle, fat and skin from another part of the body. Gracilis is a commonly used muscle for free tissue transfer. We describe our preliminary experience of its use and compare it to our large series of tug flaps.
The patients medical files were analyzed and the data were transferred to a table. Microvascular free tissue transfer in head and neck. Facial muscles may be removed during tumor excision or damaged by trauma. The volume obtainable from the inner thigh is modest,4 the pedicle length short at 6e7cm5 and the donor site is prone to breakdown and seromas. The gracilis flap is a muscular flap used in the reconstruction and rehabilitation of head and neck patients. We found the medial circumflex femoral artery perforator flap is one of. The workhorse flap in pelvic reconstruction remains the vram. The pelvic cavity was filled with the distal part of the flap figure 3 suc.
This allows recruitment of a wider skin paddle with less tension on the line of closure. Both pedicled and free flaps can be muscular or musculocutaneos the so called composite flaps. The transverse musculocutaneous gracilis flap for breast. Double free gracilis muscle transfer after complete. The transverse upper gracilis tug flap is designed from the upper medial thigh. We describe a technique of harvesting a small unit of gracilis based on its minor pedicle and maintaining the continuity and conserving the major bulk of muscle. Gracilis myocutaneous flap in reconstruction of the vulva. Treatment for complications of radiation therapy in the. This is usually done if patients do not have adequate skin and tissue in the abdomen or buttock region. Gracilis muscle is widely used in reconstructive surgery graciloplasty, either as a pedicled flap or as a free microsurgical flap. You can merge pdfs or a mix of pdf documents and other files. The technique is a secondary choice for autologous.
Tug flap breast reconstructive surgery information sheet. Gracilisbased flaps are based on the gracilis muscle, located in the upper inner thigh. In the case of the athletic patient who does not have the appropriate amount of donor site tissue to warrant a transverse rectus abdominus musculocutaneuos flap tram the transverse musculocutaneous gracilis flap tmg is an appropriate alternative. Overview of surgical techniques in genderaffirming. The urethral defect was closed using the middle part of the flap with absorbable sutures as if the muscle were a patch. Skin grafts and flaps dr ehsanur reza shovan assistant professor department of surgery. Anterolaterally, it is covered by the adductor longus and posterolaterally, at its proximal third, it is related to the adductor magnus. As with all supplements to plastic and reconstructive surgery, all subscribers have access to all of the psrc annual meeting abstracts. Transverse upper gracilis tug flap johns hopkins hospital. Perineal reconstruction may be divided into genitourinary reconstruction for acquired and congenital deformities and reconstruction for cancer. It can be harvested with a skin paddle see tug flap. Two venae, one usually slightly larger than the artery. How to merge pdfs and combine pdf files adobe acrobat dc.
We analysed the technique of the transposition of the gracilis muscle as a therapeutical option. The following case log coding recommendations have been provided in an attempt to establish some. Gracilis muscle has a class 2 vascular pedicle, with a dominant vascular. The main indication for gracilis ffmt is traumatic brachial plexus injury. Original article experience with a modified technique of. Tug flap breast reconstructive surgery information sheet this information sheet is a general guide for patients undergoing a transverse upper gracilis tug flap breast reconstruction under the care of mr paul harris. Superficial inferior epigastric perforator siep flap gluteal artery perforator gap flap transverse upper gracilis tug flap tram flap latissimus dorsi flap autologous fat transfer, using a patients fat from other body locations to fill concave deformities. When its oriented diagonally, its called a diagonal upper gracilis dug flap. The gracilis muscular flap was transferred to the pelvic cavity through a subcutaneous route. Urologygracilis flap placement urology coding ask an. Gracilis muscle transplant free flap johns hopkins.
Lower lip reconstruction using a functioning gracilis muscle free flap article pdf available in seminars in plastic surgery 242. Pdf the transverse musculocutaneous gracilis tmg flap has received little attention in the literature as a valuable alternative source of. Gracilis muscle interposition with primary rectal without. Gracilis free flap harvesting technique coverage youtube.
Urinary and fecal diversion is the firststep operation. In the distal portion, the insertion of the gracilis muscle was achieved by means of pulvertaft suturing in the tendon of the brachial biceps muscle, with the elbow kept flexed at 30o to 45o, while maintaining the muscle tension. The authors report on the first two patients treated using this technique in canada. Some authors have preferred that the proximal insertion should be made in the clavicle68, coracoid process or even in the ribs9. Gracilis free flap for smile reanimation iowa head and. Treatment for complications of radiation therapy in the cancer survivor andrew c. Internal urethrotomy is a procedure for postoperative urethral strictures of 1. The axis of the dug flap skin paddle is oriented in an oblique and posterior fashion parallel to langers lines. Without undermining, the donor site was closed directly in an almost linear scaring the gluteal fold that can be easily concealed.
The flap is sometimes known as the transverse upper gracilis tug, although this can be misleading since the flap as originally described for other forms of reconstruction has been modified to reconstruct breasts. Thank you for choosing the johns hopkins facial plastic and reconstructive. The gracilis flap is an exciting alternative to abdominal, back, or buttock tissue flaps for reconstruction. During these procedures, a flap of skin, fat, muscle and blood vessels from the upper thigh is moved to the chest to. Lower lip reconstruction using a functioning gracilis. Click, drag, and drop to reorder files or press delete to remove any content you dont want. Pdf the transverse musculocutaneous gracilis flap for breast. Our study was aimed to describe the vascular anatomy of the gracilis muscle and the related skin, in order to have a better understanding of the skins blood supply, and to help in determining a safer cutaneous paddle during transfer. Then do vessel anastomosis, then neurorraphy, then distal lateral insetting.
Use of distal part as a free flap in isolation has never been described in literature. Laparoscopic davydov correction of a failed gracilis flap. It is also split into two based on its pedicles and used as two units. A 2stage procedure with a crossface nerve graft followed by gracilis free flap inset is advocated.
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